Monthly Archives: April 2009

Current level of influenza pandemic alert raised from phase 4 to 5
29 April 2009 — Based on assessment of all available information and following several expert consultations, Dr Margaret Chan, WHO’s Director-General raised the current level of influenza pandemic alert from phase 4 to 5. She stated that all countries should immediately activate their pandemic preparedness plans. At this stage, effective and essential measures include heightened surveillance, early detection and treatment of cases, and infection control in all health facilities. (accessed 29 April 2009)

WHO and health authorities in affected countries will not have all the answers immediately, but we will get them.

WHO will be tracking the pandemic at the epidemiological, clinical, and virological levels.

The results of these ongoing assessments will be issued as public health advice, and made publicly available.

All countries should immediately activate their pandemic preparedness plans. Countries should remain on high alert for unusual outbreaks of influenza-like illness and severe pneumonia.

At this stage, effective and essential measures include heightened surveillance, early detection and treatment of cases, and infection control in all health facilities.

This change to a higher phase of alert is a signal to governments, to ministries of health and other ministries, to the pharmaceutical industry and the business community that certain actions should now be undertaken with increased urgency, and at an accelerated pace.

I have reached out to donor countries, to UNITAID, to the GAVI Alliance, the World Bank and others to mobilize resources.

I have reached out to companies manufacturing antiviral drugs to assess capacity and all options for ramping up production.

I have also reached out to influenza vaccine manufacturers that can contribute to the production of a pandemic vaccine.

The biggest question, right now, is this: how severe will the pandemic be, especially now at the start?

It is possible that the full clinical spectrum of this disease goes from mild illness to severe disease. We need to continue to monitor the evolution of the situation to get the specific information and data we need to answer this question.

From past experience, we also know that influenza may cause mild disease in affluent countries, but more severe disease, with higher mortality, in developing countries.

No matter what the situation is, the international community should treat this as a window of opportunity to ramp up preparedness and response.

Above all, this is an opportunity for global solidarity as we look for responses and solutions that benefit all countries, all of humanity. After all, it really is all of humanity that is under threat during a pandemic.

As I have said, we do not have all the answers right now, but we will get them.

The Emergency Committee, established in compliance with the International Health Regulations (2005), held its second meeting on 27 April 2009.

The Committee considered available data on confirmed outbreaks of A/H1N1 swine influenza in the United States of America, Mexico, and Canada. The Committee also considered reports of possible spread to additional countries.

On the advice of the Committee, the WHO Director-General decided on the following.

– The Director-General has raised the level of influenza pandemic alert from the current phase 3 to phase 4.
. The change to a higher phase of pandemic alert indicates that the likelihood of a pandemic has increased, but not that a pandemic is inevitable.
. As further information becomes available, WHO may decide to either revert to phase 3 or raise the level of alert to another phase.
. This decision was based primarily on epidemiological data demonstrating human-to-human transmission and the ability of the virus to cause community-level outbreaks.

– Given the widespread presence of the virus, the Director-General considered that containment of the outbreak is not feasible. The current focus should be on mitigation measures.

– The Director-General recommended not to close borders and not to restrict international travel. It was considered prudent for people who are ill to delay international travel and for people developing symptoms following international travel to seek medical attention.

– The Director-General considered that production of seasonal influenza vaccine should continue at this time, subject to re-evaluation as the situation evolves. WHO will facilitate the process needed to develop a vaccine effective against A(H1N1) virus.

– The Director-General stressed that all measures should conform with the purpose and scope of the International Health Regulations.

In the 2009 revision of the phase descriptions, WHO has retained the use of a six-phased approach for easy incorporation of new recommendations and approaches into existing national preparedness and response plans. The grouping and description of pandemic phases have been revised to make them easier to understand, more precise, and based upon observable phenomena.

Phases 1-3 correlate with preparedness, including capacity development and response planning activities, while Phases 4-6 clearly signal the need for response and mitigation efforts. Furthermore, periods after the first pandemic wave are elaborated to facilitate post pandemic recovery activities.

The current WHO phase of pandemic alert is 4.

In nature, influenza viruses circulate continuously among animals, especially birds. Even though such viruses might theoretically develop into pandemic viruses, in Phase 1 no viruses circulating among animals have been reported to cause infections in humans.

In Phase 2 an animal influenza virus circulating among domesticated or wild animals is known to have caused infection in humans, and is therefore considered a potential pandemic threat.

In Phase 3, an animal or human-animal influenza reassortant virus has caused sporadic cases or small clusters of disease in people, but has not resulted in human-to-human transmission sufficient to sustain community-level outbreaks. Limited human-to-human transmission may occur under some circumstances, for example, when there is close contact between an infected person and an unprotected caregiver. However, limited transmission under such restricted circumstances does not indicate that the virus has gained
the level of transmissibility among humans necessary to cause a pandemic.

Phase 4 is characterized by verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause “community-level outbreaks.” The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk for a pandemic. Any country that suspects or has verified such an event should
urgently consult with WHO so that the situation can be jointly assessed and a decision made by the affected country if implementation of a rapid pandemic containment operation is warranted. Phase 4 indicates a significant increase in risk of a pandemic but does not necessarily mean that a pandemic is a forgone conclusion.

Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO region. While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short.

Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way.

During the post-peak period, pandemic disease levels in most countries with adequate surveillance will have dropped below peak observed levels. The post-peak period signifies that pandemic activity appears to be decreasing; however, it is uncertain if additional waves will occur and countries will need to be prepared for a second wave.

Previous pandemics have been characterized by waves of activity spread over months. Once the level of disease activity drops, a critical communications task will be to balance this information with the possibility of another wave. Pandemic waves can be separated by months and an immediate “at-ease” signal may be premature.

In the post-pandemic period, influenza disease activity will have returned to levels normally seen for seasonal influenza. It is expected that the pandemic virus will behave as a seasonal influenza A virus. At this stage, it is important to maintain surveillance and update pandemic preparedness and response plans accordingly. An intensive phase of recovery and
evaluation may be required.

“26 April 2009 — As of 26 April 2009, the United States Government has reported 20 laboratory confirmed human cases of swine influenza A/H1N1 (8 in New York, 7 in California, 2 in Texas, 2 in Kansas and 1 in Ohio). All 20 cases have had mild Influenza-Like Illness with only one requiring brief hospitalization. No deaths have been reported. All 20 viruses have the same genetic pattern based on preliminary testing. The virus is being described as a new subtype of A/H1N1 not previously detected in swine or humans.

Also as of 26 April, the Government of Mexico has reported 18 laboratory confirmed cases of swine influenza A/H1N1. Investigation is continuing to clarify the spread and severity of the disease in Mexico. Suspect clinical cases have been reported in 19 of the country’s 32 states.

WHO and the Global Alert and Response Network (GOARN) are sending experts to Mexico to work with health authorities. WHO and its partners are actively investigating reports of suspect cases in other Member States as they occur, and are supporting field epidemiology activities, laboratory diagnosis and clinical management.

On Saturday, 25 April, upon the advice of the Emergency Committee called under the rules of the International Health Regulations, the Director-General declared this event a Public Health Emergency of International Concern. WHO is not recommending any travel or trade restrictions.”

Statement by WHO Director-General, Dr Margaret Chan on H1N1
25 April 2009

“Swine influenza In response to cases of swine influenza A(H1N1), reported in Mexico and the United States of America, the Director-General convened a meeting of the Emergency Committee to assess the situation and advise her on appropriate responses.

The establishment of the Committee, which is composed of international experts in a variety of disciplines, is in compliance with the International Health Regulations (2005).

The first meeting of the Emergency Committee was held on Saturday 25 April 2009.

After reviewing available data on the current situation, Committee members identified a number of gaps in knowledge about the clinical features, epidemiology, and virology of reported cases and the appropriate responses.

The Committee advised that answers to several specific questions were needed to facilitate its work. The Committee nevertheless agreed that the current situation constitutes a public health emergency of international concern.

Based on this advice, the Director-General has determined that the current events constitute a public health emergency of international concern, under the Regulations.

Concerning public health measures, in line with the Regulations the Director-General is recommending, on the advice of the Committee, that all countries intensify surveillance for unusual outbreaks of influenza-like illness and severe pneumonia.

The Committee further agreed that more information is needed before a decision could be made concerning the appropriateness of the current phase 3.”

The U.S. Department of Health and Human Services issued a nationwide public health emergency declaration in response to recent human infections with a newly discovered swine influenza A (swine flu) virus. HHS said “the formal declaration of a Public Health Emergency (PHE) is a tool that facilitates HHS’ preparation and mobilization for disasters and emergencies,” and “will help HHS prepare for prevention and mitigation activities by enabling Food and Drug Administration (FDA) emergency use authorizations of drugs, devices, or medical tests under certain circumstances.” Specifically, the PHE “will enable the FDA to review and issue emergency use authorizations (EUAs) for the use of certain laboratory tests to help detect the newly discovered strain of influenza and for the emergency use of certain antivirals.”

Acting HHS Secretary Charles Johnson commented, “HHS is taking these steps today to be proactive in responding to this new influenza virus by offering national tools in support of community-led preparedness and response efforts. The declaration allows us the flexibility, while we learn more about the virus and its impact in the United States, to take additional steps to fully mobilize our prevention, treatment and mitigation capabilities should those actions become necessary.” In addition to the declaration, HHS said leaders are working together across operating divisions to coordinate response to the swine flu outbreak. “For example, the FDA, the National Institutes of Health, and the Centers for Disease Control and Prevention are working together to develop a vaccine precursor that could be used to develop a vaccine for this swine flu virus.” To date, there have been 20 confirmed cases of swine Influenza A (swH1N1) in California, Texas, Kansas, New York, and Ohio. No deaths in the U.S. have been reported due to the illness. Additional cases of the virus have been confirmed in Mexico and Canada.

Eighty countries and territories will be participating in “vaccination week” campaigns in the Americas (25 April-2 May) and Europe (20-26 April). These campaigns against diseases such as influenza, measles, rotavirus, rubella and yellow fever are being combined with advocacy and social outreach activities to boost awareness of the importance of immunization. These annual initiatives focus on increasing immunization coverage, immunizing vulnerable and hard-to-reach populations as well as promoting the use of new and existing vaccines.

Rwanda became the first developing nation to introduce Prevenar, Wyeth’s pneumococcal conjugate vaccine. The first doses were administered in a rural clinic east of Kigali to Rwandan children as “the first step in the rollout of the national pneumococcal immunisation programme, which aims to vaccinate nearly all Rwandan children younger than one by the end of 2009, and all Rwandan infants on a routine basis, thereafter.” Rwanda’s Health Minister Dr. Sezibera commented, “This is a proud day for Rwanda and an important milestone for the developing world. We are committed to saving the lives and improving the health of our most precious national resource – our children. With the introduction of this vaccine, our goal of significantly reducing child death in Rwanda will now be within reach.” Dr. Julian Lob-Levyt, CEO of the GAVI Alliance, said, “We applaud the Rwandan government for taking this step, and we are proud to join them in launching a new era in the delivery of vaccines designed to close the gap between rich and poor countries and improve child mortality throughout the developing world. If fully rolled out in GAVI countries, the pneumococcal vaccine could save the lives of more than 440,000 children by 2015. This would help achieve Millennium Development Goal 4. Today’s event would not be possible without the commitment of public and private partners who are making vaccines available to the poorest countries.”

The CDC received reports of 1,505 cases of malaria among persons in the United States, including one transfusion-related case and one fatal case, with onset of symptoms in 2007. The highest estimated relative case rates of malaria among travelers occurred among those returning from West Africa. Of 701 U.S. civilians who acquired malaria abroad, 441 (62.9%) reported that they had not followed an appropriate chemoprophylactic drug regimen. Persons at risk for malaria infection should take one of the recommended chemoprophylaxis regimens appropriate for the region of travel and use personal protection measures to prevent mosquito bites.